Health inspection·September 10, 2025

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed, at 2:30 P.M. Resident 1 ran from the east unit to the west unit, proceeded to go into the dining room and sit in a chair and began screaming. Attempts were made to redirect the resident. At 5:05 P.M., Resident 1 got out of the chair, jumped on top of a resident (facility could not identify resident) lying in a recliner chair and laid on top of her. Attempts to redirect the resident were unsuccessful. The resident was physically lifted off the other resident. Resident 1 became combative, punching and kicking staff with full contact. Attempts were made to calm her, she continued to punch and kick staff. Attempts were made to medicate the resident with an antianxiety medication, Ativan. The resident refused. A telephone call made to the attending Physician with orders to send her to the emergency department for Psychiatry evaluation.The resident was sent to the hospital for an emergency commitment hospitalization (302 involuntary commitment to the hospital). The resident was evaluated, and the hospital refused the emergency commitment and ordered her to be returned to the facility. The resident was readmitted to the facility on [DATE], at 10:00 P.M. Nursing documentation continued to note her physical and verbal aggressive behaviors, often running from one nursing unit to the other located on the opposite side of the building. Despite repeated behaviors, supervision and interventions remained inconsistent. Nursing documentation dated July 27, 2025, at 11:29 A.M., revealed Resident 1 became agitated with another peer (facility could not identify resident) who had entered her personal space. Resident 1 was removed from the common area. Resident 1 proceeded to follow the resident stating she was going to spank her, raising her arm and making gestures of hitting toward the other resident. Staff intervened. A review of nursing documentation dated July 31, 2025, at 11:58 A.M. revealed that Resident 1 was observed ambulating through the east wing dining room and pushing the wheelchair of another female resident (facility could not identify this resident). Resident 1 stated, I don't like her, so I pushed her away. Staff attempted to educate Resident 1 about wheelchair safety; however, Resident 1 replied, I would do it again, I don't like her, I would push her away again. The other resident was relocated for her personal safety. A review of facility investigative documentation and nursing documentation dated August 8, 2025, at 8:40 A.M. revealed Resident 1 hit Resident 2 on the left side of her head and then grabbed her arms while in the east wing dining room. This incident was witnessed by the facility's physical therapist shortly after breakfast. Staff immediately separated the residents. As an intervention, the facility initiated every 15-minute checks, instructed staff to monitor Resident 1's behaviors, and planned for reassessment after 72 hours (August 11, 2025). Staff were also instructed to redirect the resident with alternative activities. A review of a written witness statement dated August 8, 2025 (no time indicated) by Employee 1, Physical Therapist, documented that at approximately 8:20 A.M., Resident 1 was seen hitting Resident 2 on the left side of her head near the temple and then grabbing Resident 2's arms. The incident occurred in the east wing dining room while the therapist was assisting another resident with a transfer. Resident 2 was seated in a wheelchair, and Resident 1 was standing. There was no evidence that the 15-minute checks were completed after the August 8, 2025, incident. During an interview on September 10, 2025, at 11:00 A.M., the Director of Nursing confirmed the required 15-minute checks had not been carried out. A review of facility investigative documentation dated August 11, 2025, at 4:05 P.M. revealed that Resident 1 was observed pulling Resident 3's hair in the east wing dining room. This incident was witnessed by nursing staff. The residents were separated, and the incident was reported to state agencies as well as the local police. A new intervention was initiated requiring one-to-one (1:1) supervision for Resident 1. A review of the Interdisciplinary Team (IDT) documentation dated August 12, 2025, at 9:27 A.M. revealed the team met to discuss the August 11, 2025, incident. The IDT note documented that Resident 1 was not to pull Resident 3's hair and was placed on 1:1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few supervision until she could be evaluated by psychiatric services. Resident 1 was counseled about the incident but demonstrated no remorse, stating, I don't care, I don't care. The IDT documentation did not reference the prior August 8, 2025, incident or the intervention requiring 15-minute checks. The note instead indicated that 15-minute checks would continue until the reassessment 72 hours later. A review of a psychiatric consultation notes dated August 12, 2025, at 2:15 P.M. revealed that Resident 1 was seen seated in the dining room where she pulled another resident's hair (Resident 3). The note did not reference Resident 1's earlier incidents of aggression, including the August 8, 2025, and August 11, 2025, resident-to-resident altercations. The psychiatric note also failed to mention that Resident 1 had been placed on 1:1 supervision by the facility. A review of facility investigative documentation dated August 27, 2025, at 11:30 A.M. revealed Resident 1 stood from her chair in the east wing dining room and approached Resident 3. The staff member assigned to provide 1:1 supervision followed closely and attempted to intervene by standing between the residents and raising her hand to block Resident 1. Resident 1 reached around the staff member and pulled Resident 3's hair. The residents were immediately separated. The incident occurred prior to lunch in the dining room, which was described as a noisy and highly stimulating environment. Staff were instructed to redirect Resident 1 to quieter areas and to continue 1:1 supervision. Clinical record review revealed that Resident 3 was admitted to the facility October 4, 2023, with diagnosis to include dementia and was severely, cognitively impaired with a BIMS score of 1. A review of facility investigative documentation dated September 8, 2025, at 8:25 P.M. revealed that Resident 1 stood up from her chair in the east wing dining room, walked over to Resident 4, and struck her on the back. The resident was redirected out of the dining room by staff. Documentation indicated Resident 1 had stated beforehand, I'm going to spank her. The intervention at that time was to continue 1:1 supervision, and nursing staff were reeducated to remain within arm's reach of the resident during 1:1 observation. A review of a witness statement dated September 8, 2025 (no time indicated), from Employee 2 (NA), Nurse Aide, revealed Resident 1 was seated near a window in the dining room and appeared to be asleep. Employee 2 (NA) was three chairs away, looking at personal phone messages, when Resident 1 suddenly stood up, approached Resident 4 (seated in her wheelchair), and struck her on the shoulder with an open hand. Employee 2 (NA) then redirected Resident 1 using her gait belt and escorted her to the meditation room (off the unit). Clinical record review revealed Resident 4 was admitted on [DATE], with diagnoses including dementia. Resident 4 was severely cognitively impaired with a BIMS score of 1. Nursing documentation revealed Resident 4 wandered frequently throughout the unit, entered other residents' rooms, and displayed disruptive vocalizations such as continuous shouting. The noted intervention for August 8, 2025, resident to resident incident was to implement every 15-minute staff monitoring. There was no evidence at the time of the survey that this intervention was implemented to prevent future incidents of resident abuse. Review of interventions revealed that following the August 8, 2025, incident, every-15-minute monitoring was ordered but not implemented. Following the August 11, 2025, incident, 1:1 monitoring was ordered. A review of 1:1 monitoring records dated August 11, 2025, through the date of survey revealed multiple gaps in documentation, including but not limited to: August 11, 15, 19, 20, 23, 25, 26, 27, 28, 29, 31; September 1, 2, 3, 4, 6, 7, and 8, 2025. Despite Resident 1's documented pattern of aggressive and intrusive behaviors, the facility failed to ensure consistent supervision and monitoring. As a result, Residents 2, 3, and 4, all severely cognitively impaired residents, were subjected to repeated physical abuse including hitting and hair-pulling. During an interview with the Nursing Home Administrator and the Director of Nursing on September 10, 2025, at 2:00 P.M., both confirmed the facility failed to prevent Resident 1 from physically abusing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Broad Mountain Health and Rehabilitation Center 500 West Laurel Street Frackville, PA 17931 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm (hitting and pulling hair) Residents 2, 3, and 4. The facility failed to implement sufficient supervision and monitoring measures to address Resident 1's known history of aggression, resulting in physical abuse of three residents. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.29(a)(c) Resident Rights28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(c)(d)(5) Nursing Services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395286 If continuation sheet Page 4 of 4